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Show Table 1. Medicare Clinical Performance Monitoring System: Utah, 1998-2000. Setting Clinical Topic Area Indicator Indicator Rates Baseline (1998) Remeasurement (2000) Relative I improvement*^ Evaluation of ejection fraction and treatment with Heart Failure angiotension-converting enzyme (ACE) inhibi- 78.2% 83.5% 24.3% tors*** Warfarin for atrial fibrillation 56.8% 64.6% 18.1% Stroke Prevention and Treatment Aspirin antiplatelets for stroke and transient ischemic attack 86.0% 88.2% 15.7% Avoiding inappropriate use of sublingual nifedipine 91.7% 98.2% 78.3% Early administration of aspirin 83.3% 86.7% 20.4% Aspirin at discharge 90.2% 93.4% 32.7% Early administration of beta blockers 57.8% 74.9% 40.5% Acute Myocardial Infarc- Beta blockers at discharge 67.9% 88.2% 63.2% Inpatient tion ACE Inhibitors for low left ventricular ejection fraction 79.2% 78.0% -5.8% Time to initial reperfusion**** 43.0 min. 29.9 min. 13.1 min***** Smoking cessation counseling 51.1% 60.9% 20.0% Initial antibiotics administered within 8 hours of arrival 88.1% 89.6% 12.2% Initial antibiotics consistent with current recommendations 84.8% 85.7% 5.6% Pneumonia If done, blood cultures obtained before antibiotics administered 81.7% 83.6% 10.1% Patient screened for or given influenza immunization 19.0% 51.5% 40.2% Patient screened for or given pneumococcal pneumonia vaccination 16.8% 48.5% 38.1% Annual Glycosylated Hemoglobin Ale (HbAlc) 79.1% 84.8% 27.2% Diabetes Treatment Biennial Eye exam or visit with an eye care professional 68.9% 72.0% 10.1% Biennial lipid profile 55.6% 77.4% 49.2% Outpatient Cancer Screening Biannual mammography (non-HMO females aged 52-69) 54.7% 60.2% 12.3% Influenza immunization rate 75.1% 74.3% -3.4% 1 mmunization Pneumococcal vaccination rate 61.3% 64.1% 7.3% indicator definitions include ideal candidates for therapies only. **Exceptfor "Time to initial reperfusion" relative improvement is calculated as: (remeasurement - baseline)/(100% - baseline) ***This indicator was reported as two separate indicators (ejection fraction evaluation and use of ACE inhibitors) in the Medicare quality of care monitoring system, but combined into one indicator for QIO evaluation. ****This indicator was reported as two separate indicators (time to angioplasty and time to thrombolytic therapy) in the Medicare quality of care monitoring system, but combined into one indicator for QIO evaluation. *****Reduction in median time to initial reperfusion.____________________________________________________________________________________ • Diabetes - 9th • Mammography- 17th • Immunization - 50th Utah's overall ranking on the combined outpatient clinical topic areas declined by 7 positions, from #15 at baseline to #22 at follow-up. DISCUSSION AND LIMITATIONS The limitations of the clinical performance monitoring system relate, in large part, to the purposes of analysis. The sample sizes and measurement reliability are generally adequate for analysis of clinical topic areas at a statewide level. Results observed at the statewide level and comparisons with national trends can be taken as reliable indicators of the pace and effectiveness of health care quality improvement in Utah during this time, although some possible exceptions have been noted. The measurement system was developed, in part, to evaluate the effectiveness of Medicare QIOs nationally, hi the 6th SOW, QIO performance was evaluated based on statewide improvement in quality indicator rates. This produced no incentive for designating control or reference groups of providers or facilities within a state. The only meaningful comparisons available are comparisons with national trends. It must be noted that Healthlnsight activities constitute only one of many factors that might contribute to differences between improvement observed in Utah and in other states. Inpatient Clinical Topic Areas Utah saw extraordinary levels of improvement in the inpatient clinical topic areas during this time, improvement that far outpaced national trends. Good performance (in the top quartile) was observed hi heart failure and stroke, the inpatient clinical topic areas with indicators less closely related to core hospital processes, and exceptional performance (first in the nation) was observed hi the acute myocardial infarction and pneumonia treatment. As of the final measurement period, Utah ranks first in the nation on this set of indicators. Credit for this success can be reliably attributed to the improvement efforts of Utah providers. Improvement hi these areas translates to reduced mortality, reduced secondary complications, more effective use of health care resources, reduced hospitalizations, and disease prevention. It is not possible to isolate Healthlnsight's contribution to this success, nor is it even possible to disaggregate the impact of separate elements of Healthlnsight''s multifaceted intervention. However, the results observed in Utah, and the greater body of evidence from other industries, suggest integration of human factors and safety management principles as a promising approach for health care quality improvement efforts. Outpatient Clinical Topic Areas Overall, Utah saw less than average levels of improvement in outpatient clinical topic areas during this time. The overall average obscures top quartile performance in diabetes treatment and above average performance in mammography screening. Interpretation of outpatient immunization performance may be tempered by examination of longer trends. Going back to 1993, these data (from the Behavioral Risk Factor Surveillance Sys- 135 Utah's Health: An Annual Review Volume DC |